More on timely access in health care

Back in September, Gady posted about California’s Timely Access Law, a 2002 law which set out to regulate how quickly HMO’s had to see patients. The LA Times had a recent update (California limits HMO wait times, Jan 19) since the state’s Department of Managed Health Care has finally formalized regulations. (If you think that health care reform has taken a long time through Congress, it has taken California seven years to formalize seemingly simple rules on how long it should take to see a doctor.) Here is what the standards are:

The regulations by the California Department of Managed Health Care, in the works for much of the last decade, will require that patients be treated by HMO doctors within 10 business days of requesting an appointment, and by specialists within 15. Patients seeking urgent care that does not require prior authorization must be seen within 48 hours. Telephone calls to doctors’ offices will have to be returned within 30 minutes, and physicians or other health professionals will have to be available 24 hours a day.

To put that performance in perspective, consider this:

One 2009 study that has been cited by state officials found that consumers in California’s two largest cities face extended delays when trying to get medical services. People in San Diego wait an average of 24 days for a routine physical with a family practitioner, according to the survey by Merritt Hawkins & Associates, a national physician recruiting firm. In Los Angeles, patients wait 59 days on average.

An obvious question is why waits are so bad. Insurance companies and doctors want to make money but that doesn’t necessarily translate into crappy service. I am willing to believe that the average doctor will put his or her patients’ well being over and above making a buck and to the extent long waits jeopardize patient health, the average doctor would like to reduce waits. It may simply be that there are not enough doctors in California (or enough of the right kind of doctors). The Merritt Hawkins survey mentioned above concluded that “Los Angeles’ high cost of living, its vast poor population and low reimbursement rates from Medi-Cal drive family doctors away from the city or into specialties that offer higher pay.” If too few doctors is really the root cause of the problem, I don’t expect this law will make an immediate improvement. A shortage of primary care physicians is a national issue, not a California specific problem (Reform just won’t work without more family doctors, Jan 19, IndyStar.com):

Unfortunately, the national discussion regarding how to provide health insurance for the 50 million uninsured largely ignores a smoldering crisis: Although there is a projected shortage of all physicians, there is a critical lack of family and other primary-care physicians to provide the care necessary if significantly more Americans were insured. … Only a small fraction of medical school graduates are choosing careers in primary-care fields, including family medicine. Since 1997, the number choosing family medicine has dropped by 50 percent despite the fact that we will need 40 percent more primary-care physicians by 2020. Using physician extenders such as nurse practitioners can help, but it’s not the solution.

So is there another solution? One possibility a move toward open access scheduling. Here is how a Slate article described how it is suppose to work (Available Jones, M.D., Sep 4 2007)

When a patient calls in the morning asking to see a doctor who uses open access, the office offers an appointment for that same day. Why are there openings available? Well, the main reason most doctors defer today’s work to some time in the future is that today’s schedule is clogged with appointments made weeks ago. Doctors following the same-day scheduling model, on the other hand, are free today because they saw yesterday’s patients yesterday. Using open access, doctors might still schedule some early-morning appointments in advance, for follow-up visits or for patients who actually prefer a future appointment. But the key is that they keep most of their time free for same-day visits and fill up their schedules as the day goes.

Put another way, a system with adequate capacity can have a large seemingly permanent backlog even if it on average has enough capacity. That is, wicked long waits to see a primary care physician in Los Angeles may mean that they are out of capacity but it doesn’t prove that they are out capacity. Traditional medical scheduling systems can result in very bad performance even when there is sufficient capacity. Intuitively, this happens for the same reason queues build up in any service system. The system may on average have enough capacity but it can be swamped by variability on a given day. The issue is how the system responds to this surge in demand. Traditional systems force the patient to adjust — i.e., to wait. That is how Tuesday’s patient isn’t seen until Friday. Open access essentially forces the medical staff to adjust and expand hours of operations. The question becomes how frequently is the system willing to work over time? If doctors are willing to put in hours when needed, it may be that open access can improve responsiveness without greatly expanding resources.

How soon will we know whether California’s attempt to legislate waits works? We really won’t know until next year:

After the rules are unveiled Wednesday, HMOs will be given nine months to submit plans that meet the new guidelines, allowing for the fact that many HMOs will need to revise their contract agreements with physician networks and other groups. HMOs will be given until January 2011 to comply; after that, the managed healthcare department will have the authority to penalize HMOs that fail to ensure timely care. People will be able to complain to the department about delays.

However, you should also know that doctors have an out:

Regulators, however, say flexibility is built into the new rules. For example, doctors can use their professional judgment to extend the waiting time if they determine that a delay will “not have a detrimental impact on the health of the enrollee.”